Commercial Combination Insurance Application Entire Application Must Be Completed and Signed

Transcription

1 CANAL INSURANCE COMPANY CANAL INDEMNITY COMPANY 1. GENERAL INFORMATION Applicant Legal Name Company Name (DBA) (if any) Commercial Combination Insurance Application Entire Application Must Be Completed and Signed Date and Time Coverage is Bound by Canal Requested Effective Date Form of Business Canal General Agent Use Only LOUISIANA Individual LLC Partnership Corporation Joint Venture Other Principal or Majority Owner (please include all principals) DOT Number Telephone Number Mobile Phone Number *Tax Identification Number or Social Security Number Address Fax Number Location of Business Premises or Physical Address Location Is Inside City Limits Outside City Limits Mailing Address (if different than above) *If provided, certificates of insurance can be accessed from 24 hours a day. 2. GENERAL QUESTIONS Policy Type Scheduled Vehicle Gross Receipts (only available for 25 or more power units) Gross Mileage (only available for 25 or more power units) How long has this operation been in business? Less than one year One to two years Two or more years Have you ever had insurance with Canal? If yes, please provide policy number or year(s) and name on policy. Business Class For Hire Trucking (hauls goods for others) Private Carrier (hauls owned goods) Public Auto/Taxi Non Trucking Small Commercial If applying for Non-Trucking Coverage list name and the motor carrier number of the lessee to whom you are permanently leased. Name of Motor Carrier Motor Carrier Number If applying for Small Commercial, describe type of business and use of vehicle(s). Type of Business Use of Vehicle(s) Do you own any other businesses? If yes, please provide the name, address and details. Have there been any changes in the ownership, management or name of the operation in the past five years? If yes, please provide details. Indicate Policy Term and Payment Method Short Term Policy* Desired Expiration Date: *(No company payment plan available for short term policies.) Continuous Until Cancelled Policy (2 month escrow deposit and monthly billing) Annual Policy: Full Payment to Company Company Payment Plan Financed through outside Premium Finance Company with full payment to Canal (no double financing permitted attach contract) 3. MOTOR CARRIER FILINGS Do you need an MCS-90? Authority Type Common Contract Brokerage If brokerage, please provide the percentage of total revenue generated by brokerage operations and MC number Form A-101 LA Page 1 of 7 (8-2008)

2 MOTOR CARRIER FILINGS continued Filings Required Motor Carrier # Applicant s Name and Address Exactly As It Appears On Each Permit Liability BMC 91X Cargo BMC 34 MC Liability Form E Oversized/Overweight Hazardous Cargo Form H State State SR 22- If yes explain If an MCS-90 is issued, Canal will issue with the required limits as posted on the FMCSA website. Please note: 36 days notice of cancellation is mandatory on all policies that have an MCS-90 or filings. Canal requires all units to be scheduled when an MCS-90 or filings are issued. 4. OPERATIONS Please Identify Metropolitan Areas Traveled Through or Into Atlanta Cleveland Jacksonville Milwaukee Philadelphia San Diego Baltimore/DC Dallas/Ft. Worth Kansas City Mpls/ St. Paul Phoenix San Francisco Boston Denver Little Rock Nashville Pittsburgh Seattle Buffalo Detroit Los Angeles New Orleans Portland Tulsa Charlotte Hartford Louisville New York City Richmond Chicago Houston Memphis Oklahoma City St. Louis Cincinnati Indianapolis Miami Omaha Salt Lake City Do you act as a freight forwarder, freight broker or arrange loads for others? Do you lease to others? Do you allow guest passengers? Do you haul double trailers? Do you haul triple trailers? Are any vehicles used to transport employees? Do you hire owner operators on a trip lease basis? Do you lend, lease or rent trucks, tractors or trailers to others without drivers? Please explain all Yes answers 5. HISTORY Have there been any losses in the current year or the past three years? If yes, please complete below. Please complete for all lines of business for the current year, as well as for the three years prior, or submit loss runs. Policy Term Liability Physical Damage From To Company Name Month Year Month Year # Claims *Amount Incurred # Claims *Amount Incurred Attach separate loss runs if space provided is not sufficient. *Amount incurred should include paid as well as reserved total. Policy Term Cargo General Liability From To Company Name Month Year Month Year # Claims *Amount Incurred # Claims *Amount Incurred Attach separate loss runs if space provided is not sufficient. *Amount incurred should include paid as well as reserved total. Please describe all claims over $10,000 Form A-101 LA Page 2 of 7 (8-2008)

3 6. DRIVERS I declare the following list includes all drivers of vehicles requested to be covered under the policy including employees, leased employees, owner operators, mechanics, family members, and any other person allowed to drive an insured vehicle. Driver License Driver Name Date of Birth State Driver License Number No. of Moving Violations in Past 3 Years No. of Accidents in Past 3 Years Year Hired Years of Experience Have any drivers been convicted of any of the following? Negligent homicide, unlawful use of vehicle, speed contest or racing, reckless driving, leaving the scene of an accident or a hit and run, any felony conviction which involves a motor vehicle, speed twenty miles or more over the speed limit or driving while license is suspended or revoked in a commercial vehicle, DUI or DWI. If yes, please provide driver name and details. Do you agree to report all drivers to your agent prior to them driving an insured unit? Do you comply with all DOT regulations concerning driver employment, files and regulations? 7. VEHICLES Description of Vehicles (trailers must be scheduled for liability coverage to apply while detached from a power unit) Unit No. Model Year Make and Unit Type Serial Number Number of Axles GVW *Owner Type **Is Garaging address same as physical? *Please enter the owner type by entering the corresponding number. 1. Owned by Named Insured, 2. Owned by Leasing Company (long term lease without a driver), 3. Owned by Owner Operator (leased with driver), 4. Owned by Employee of Named Insured (officer) **If a unit is not garaged at the physical address, it is necessary to complete the sections below for additional garaging addresses. Name and address of vehicle owners other than the named insured (owner types 2, 3 & 4 listed above) Unit No. Name of Owner Mailing Address Please note that coverage for owners might not be afforded if this section is not completed. **If a unit is not garaged at the physical address of the applicant, please complete the garaging addresses for each unit Unit No. Street Address Unit No. Street Address Form A-101 LA Page 3 of 7 (8-2008)

4 VEHICLES (continued) Are all owned and operated power units listed on this application? If no, please provide details. Do you have any mobile equipment subject to financial responsibility laws? If yes, please provide details of equipment. 8. PRIMARY OPERATION Please indicate the percentage of operations for each of the following: Dump Flatbed Log Hauling Refrigeration Tank Dry Van Auto Hauler Mobile Home Toter Driveaway Double Trailer Hauler Other Are any of the following commodities hauled? Hazardous Materials Requiring 1,000,000 Liability Limits or Less Hazardous Materials Requiring 5,000,000 Liability Limits Refuse/Waste/Garbage Explosives If yes, please provide details. Commodities Transported (Please be specific - general freight and miscellaneous is not acceptable) % Type % Type 9. COVERAGE SELECTION It is only necessary to complete sections for desired coverage. If a coverage section is left blank it will be understood that no coverage is desired. 9. AUTO LIABILITY Commercial Vehicles Taxicabs Only Combined Single Limit - each accident Bodily Injury - each person Bodily Injury - each accident Property Damage - each accident $ $ / $ / $ Please indicate the desired radius restriction if less than an unlimited radius is desired (FL and CT only) For an unlimited radius please indicate the percentage of trips by radius from the physical address. Percentage of Trips by Radius Over 300 Additional/Designated Insureds Name Mailing Address *Type of Additional Insured *Please enter each desired additional/designated insured by entering the corresponding number: 1. Designated Additional Insured, 2. Intermodal, 3. Additional Insured Waiver Rights Recovery, 4. Additional Insured Hired/Non-Owned 9. AUTO PHYSICAL DAMAGE Please complete for all units that desire physical damage coverage. Unit No. Physical Damage Limit Name of Loss Payee Loss Payee Complete Address Form A-101 LA Page 4 of 7 (8-2008)

5 AUTO PHYSICAL DAMAGE (continued) Deductible Desired- Please select one $500 $$1,000 $2,500 $5,000 (submit for approval) Coverage Desired Collision and Specified Causes of Loss Collision and Comprehensive (not available in all states) Additional Coverages Desired Additional Towing Limit $ (in the event of a total loss to the described unit) $2,500 included Trailer Interchange Limit $ Minus $1,000 Deductible (UIIA container haulers) Non-Owned Trailer Limit $ Minus $1,000 Deductible (coverage applies only while attached to a scheduled power unit) Please list the name and address of owners of Non-Owned trailers Name of Owner Address of Owner 9. MOTOR TRUCK CARGO Coverage for cargo in trailers applies ONLY while trailer is attached to a scheduled power unit. Limit Desired Per Vehicle $ Units that require specific limits other than above, please indicate below. Unit No. Desired Limit Unit No. Desired Limit $ $ Deductible Desired- Please select one $500 (available only on limits up to $25,000) $1,000 $2,500 $5,000 (submit for approval) Additional Coverages Desired Refrigeration Breakdown - $2,500 minimum deductible required Poultry Cages Water Damage - $2,500 minimum deductible required Earned Freight Increase to $ $1,000 included Debris Removal Increase to $ $10,000 included 9. TRUCKERS GENERAL LIABILITY This application is for General Liability Coverage on businesses solely involved in for-hire transportation of property. Desired Limits General Aggregate - please select one $1,000,000 $2,000,000 Each Occurrence $1,000,000 (included) Employers Liability (Stop Gap) Coverage Applicable only in ND, OH, WA and WY. Please select either yes or no. Limits $1,000,000 Bodily Injury by Accident - each accident $1,000,000 Bodily Injury by Disease - each employee $1,000,000 Bodily Injury by Disease - each policy Do you haul bulk fuel? If yes, a $1,000 deductible applies. If desired, please indicate an optional higher deductible $ Do you repair or service vehicles of others? Do you have dogs at premises? (see exclusion endorsement) Do you carry a firearm? (see exclusion endorsement) Do you generate income from other activities besides the operation of the trucks? Please explain all Yes answers Please list all mobile equipment owned by the applicant, if any (i.e. forklift, backhoe, mobile crane, etc.) Form A-101 LA Page 5 of 7 (8-2008)

6 TRUCKERS GENERAL LIABILITY (continued) Please list all premises owned or rented Street Address Street Address Street Address Additional/Designated Insureds Name Mailing Address *Type of Additional Insured *Please enter each desired additional/designated insured by entering the corresponding number: 1. Controlling Interest, 2. Designated Person or Organization, 3. Managers or Lessors of Premises, 4. Mortgagee, 5. Owners, Lessees or Contractors, 6. Co-Owner of Insured Premises, 7. Vicarious Liability for Owners, Lessees or Contractors 10. CERTIFICATES OF INSURANCE Name Mailing Address 11. MVR AND CREDIT REPORT ACKNOWLEDGEMENT I authorize Canal Insurance Company to obtain a copy of any Motor Vehicle Report for rating/underwriting the insurance for which I have applied. I also understand that a routine inquiry may be made providing information concerning my character, general reputation, personal characteristics and mode of living. Upon written request, information as to the nature and scope of the report will be provided to me. Disclosure: In connection with this application for commercial automobile insurance, we may review a credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of the insurance score. Your credit report/credit-based insurance score will not be used for any purpose other than the underwriting of the commercial automobile insurance policy for which you have applied. Under no circumstances can the credit-based insurance score, the lack thereof, or the refusal to authorize the obtaining of a credit report or a credit-based insurance score be a factor in determining your eligibility for commercial automobile insurance, including cancellation or nonrenewal, if a policy is ultimately issued. I authorize Canal Insurance Company to obtain a credit report, including but not limited to a credit-based insurance score based on personal information provided. This authorization is valid for future reports obtained for renewal policies with Canal Insurance Company. Applicant s Signature Date Form A-101 LA Page 6 of 7 (8-2008)

7 12. ACKNOWLEDGEMENT AND SIGNATURE I hereby certify that the information contained in this application is true and agree that a misrepresentation of any of the facts by me will constitute reason for the company to void or cancel any policy issued on the basis of this application, and will hold the company harmless for the action taken. I also agree that if a policy is issued pursuant to this application, the application and any elections or rejections, which are included with the application and signed by me, may be relied upon by the company as accurate and shall become a part of the policy. I recognize that all or parts of my operations are under the Department of Transportation oversight requiring me to adhere to their rules and regulations. I acknowledge that DOT rules and regulations are understood by me, and I will adhere to the rules and regulations including, but not limited to, driver hiring, vehicle inspection, maintenance and hours of service. LOUISIANA FRAUD WARNING Any person who knowingly presents a false or fraudulent claim for payment of a loss of benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Signature of APPLICANT Type or Print Applicant Name Title or Relationship to Applicant Date Application Completed X Signature of AGENT of the Applicant Agency Name Address of Agency X Premium Calculations (agent use only) Coverage Premium Auto Liability Auto Physical Damage Motor Truck Cargo Truckers General Liability Deposit or Down Payment Number of Installments Amount Enclosed Total Form A-101 LA Page 7 of 7 (8-2008)

8 CANAL INDEMNITY COMPANY LOUISIANA SUPPLEMENTAL APPLICATION MUST be completed in conjunction with Form A-101 LA only if Auto Liability Coverage is requested 1. Applicant Name Date: 2. DBA, if any LOUISIANA FRAUD WARNING Any person who knowingly presents a false or fraudulent claim for payment of a loss of benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. UNINSURED/UNDERINSURED MOTORIST COVERAGE SELECTION / REJECTION In accordance with the provisions of Louisiana law, please select Uninsured/Underinsured Motorists Bodily Injury Coverage (UMBI) on the State of Louisiana form (page 2). The options and premiums are listed below. UMBI other than gas or petroleum haulers UMBI gas or petroleum haulers Economic Only UMBI other than gas or petroleum haulers Economic Only UMBI gas or petroleum haulers LIMITS 10/ / / / / / / / / / / / / / / / / , , / , , / / , ,238 If you choose UMBI and do not carry collision coverage, you may also select Uninsured Motorists Property Damage Coverage (UMPD) which will pay up to $10,000 or the actual cash value (ACV) of the insured vehicle, whichever is less, subject to a $250 deductible. The UMPD coverage requires the payment of additional premium. The option and premiums are listed below. Please make your selection of coverage by initialing below. If you do not initial below then you will not have this coverage. Other than gas or petroleum haulers Gas or petroleum Haulers 10,000 or ACV, whichever is less (Initial) FOR RATES AND LIMITS NOT DISCLOSED, REFER TO COMPANY. The selections have been explained to me by my agent and I understand they will remain in effect and will apply to any renewal, reinstatement or substitute policy unless I notify you otherwise in writing. I UNDERSTAND THAT MY SELECTION OR REJECTION OF COVERAGE IS BINDING ON ALL PERSONS INSURED UNDER THIS POLICY. Signature of Applicant X X Signature of Agent of Applicant THIS IS NOT A BINDER Form A-101 LA SUPP Page 1 of 2 (4-2007)

9 State of Louisiana This form is in compliance with LSA R.S. 22:680. This form may not be altered or modified. UNINSURED/UNDERINSURED MOTORIST BODILY INJURY COVERAGE FORM Uninsured/Underinsured Motorists Bodily Injury Coverage, referred to as "UMBI" in this form, is insurance which pays persons insured by your policy who are injured in an accident caused by an owner or operator of an uninsured or underinsured motor vehicle. By law, your policy will include UMBI Coverage at the same limits as your Bodily Injury Liability Coverage unless you request otherwise. If you wish to reject UMBI Coverage, select lower limits of UMBI Coverage, or select Economic-Only UMBI Coverage, you must complete this form and return it to your insurance agent or insurance company. (Economic-Only UMBI Coverage may not be available from your insurance company. In this case, your company will have marked options 3 and 4 below as "Not Available.") UNINSURED/UNDERINSURED MOTORIST BODILY INJURY COVERAGE You may select one of the following UMBI Coverage options (initial only one option): 1. I select UMBI Coverage which will compensate me for my economic and non-economic losses with the Initials same limits as my Bodily Injury Liability Coverage. Economic losses are those which can be measured in specific monetary terms including, but not limited to, medical costs, funeral expenses, lost wages, and out of pocket expenses. Non-economic losses are losses other than economic losses and include, but are not limited to, pain, suffering, inconvenience, and mental anguish and other non-economic damages otherwise recoverable under the laws of this state. 2. I select UMBI Coverage which will compensate me for my economic and non-economic losses with Initials limits lower than my Bodily Injury Liability Coverage limits: $ each person $ each accident 3. I select Economic-Only UMBI Coverage which will compensate me only for my economic losses with Initials the same limits as my Bodily Injury Liability Coverage. 4. I select Economic-Only UMBI Coverage which will compensate me only for my economic losses with Initials limits lower than my Bodily Injury Liability Coverage limits: $ each person $ each accident 5. I do not want UMBI Coverage. I understand that I will not be compensated through UMBI Coverage Initials for losses arising from an accident caused by an uninsured/underinsured motorist. SIGNATURE The choice I made by my initials on this form will apply to all persons insured under my policy. My choice shall apply to the motor vehicles described in the policy and to any replacement vehicles, to all renewals of my policy, and to all reinstatement or substitute policies until I make a written request for a change in my Bodily Injury Liability Coverage or UMBI Coverage. Named Insured or Legal Representative (Please Print) Signature of a Named Insured or Legal Representative X Policy Number Date THIS IS NOT A BINDER Form A-101 LA SUPP Page 2 of 2 (4-2007)